A Clinical Risk Case Study- Failure to Perform the Consented Procedure

Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Miss Lorna Phelan BM BS MRCOG RCOG, Consultant Obstetrician and Gynecologist

The Scene

A 40-year-old woman had been suffering from symptoms of mid-cycle pain for some 13 years, therefore her GP subsequently referred her for gynaecology review. On review, she was diagnosed with cysts on both ovaries.

The patient consented to a hysterectomy with the removal of her ovaries and both fallopian tubes, however, during the operation, the gynaecological surgeon only performed a hysterectomy with a right salpingectomy and did not remove her ovaries as planned.

A claim was subsequently brought against the Consultant Gynecologist in relation to a failure to perform the procedure that had been expected and originally consented to (salpingo-oophorectomy).

TMLEP’s Independent Clinical Findings

TMLEP’s independent review concluded that the care afforded to the Claimant fell below the reasonable standard of care as the surgeon failed to perform the operation as discussed with and consented for by the Claimant.

Ultimately, it would have been acceptable to have left the ovaries in situ, and not completed this part of the operation in the event that this could be justified on surgical grounds (i.e. the surgery was deemed too complex upon opening the abdomen). Such justification, however, was absent from this case.

In relation to the right ovary, the surgery was determined to be too complex and albeit it would have been possible to seek additional surgical assistance and remove the ovary with assistance, it was nonetheless a reasonable decision to have left this ovary in situ during the operation.

In relation to the left ovary, however, there were no grounds at all to justify the ovary being left in place, therefore, this was a clear instance of substandard clinical care.

Our independent findings concluded that the failure to remove the Claimant’s left ovary was clearly substandard, resulting in the Claimant’s symptoms persisting until the point where they had to subsequently undergo further surgery to remove the ovary. If the ovary had been removed as originally planned then she would not have had to have undergone further surgery and the additional inherent risks this carried.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

1. Surgeons should always be mindful of the expectation the patient has as to what to expect during the operation.

2. Surgeons should be mindful as to the nature of the operation consented to.

3. Surgeons should be cautious in varying the operation during surgery without clear justification, such as the surgical risks or patient benefit.

4. As in this case, if any portion of surgery is considered by the surgical team prior to surgery to be a 'possibility' rather than 'firmly agreed', pending the findings on opening the abdomen, then this should be communicated clearly with the patient beforehand and documented on the consent form.

5. Patient expectations have to be managed realistically; just as one would not remove an ovary without prior consent, one also, should not leave one behind when previously agreed that it would be removed.

To Conclude

In order to help resolve the Claimant’s long-standing mid-cycle pain, the Claimant should have had her left ovary removed as discussed and consented for during her first operation.

There was no surgical reason not to remove the left ovary and was, therefore, not in the Claimant’s best interest to leave this ovary in-situ. As a consequence, the Claimant had to undergo a second and high-risk operation.

In this case, the standard of care fell below the standard expected of a reasonably competent practitioner and furthermore could not be logically supported by a responsible body of medical opinion.


Important Notice: This article is intended to raise awareness of clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0)203 355 9796.

The TMLEP Clinical Risk and Patient Safety Publishing Group and Miss Lorna Phelan BM BS MRCOG RCOG, Consultant Obstetrician and Gynaecologist. (2018). A Clinical Risk Case Study- Failure to Perform the Consented Procedure. TMLEP Clinical Risk Case Studies. 1 (5), 1.